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P.. <br />WASrs <br />Front Range Landfill <br />FRONT RANGE LANDFILL <br />C PO Box 320 <br />Erie. CO 80516 <br />Weighed: Jo C <br />BILL TO: 11234 <br />PALMETTO ENVIRONMENTAL <br />4995 YORK ST <br />DENVER CO 80216 <br />Vehicle ID: <br />Reference: FRL -14 -055 <br />arid: FRL -WK1 <br />NOTES:: COLORADO FLAGSTONE <br />YARDS:: 4301 N COUNTY RD 27 <br />PO4:: LOVELAND. CO 80538 <br />DATE IN: 09/04/2014 TIME IN: 14:56:18 <br />DATE OUT: 09 /04/2014 TIME OUT: 14:56:18 <br />INBOUND TICKET Number: 03- 01030029 <br />SCALE 1 GROSS WT. <br />54640 LB <br />MANUAL TARE WT. <br />23880 LB <br />NET WEIGHT <br />30760 LB <br />Qty Description <br />Amount <br />10.00 SW -Yard <br />140.00 <br />TICKET AMOUNT: <br />140.00 <br />rX <br />I /WE THE UNDERSIGNED, CERTIFY THAT THE <br />WASTE DELIVERED FOR DISPOSAL IS <br />NON - HAZARDOUS SOLID WASTE MATERIALS. <br />Operating Hours: M -F 6 am- 5 PM, Sat 6am -2pm <br />PHONE: 303- 673 -9431 <br />Xame of Driver jrint /type) <br />Manifest Number: 0516 <br />RD -OUS WASTE "'Approval Number. <br />WIFEST <br />Expiration Date: <br />lerator Information (generator to complete) <br />,Lk s i Site Name. dT,�9�� <br />1 � f� I Address: 3•3i U ( 7 <br />City, State: L <br />Zip: 3 <br />Contact Person: <br />Phone #:',i)) -5811-5213 Fax : <br />Consultant: RA I P' e 4a <br />i V% A6J 41k Address: `°1-A q S Y * kr � •€ r 4 2 <br />r oi g r -b-ii City, State: <br />VS'II Zip: <br />130 -716 <br />Tons Contact Person: <br />Phone #:301 M-3114 Fax: y ,3-S34-504q <br />al represented on the Special Waste Application identified by the above Special <br />to transporter on the shipment date referenced below. <br />gnature of Generator's Authorized Agent hipment Date <br />ter Information (transporter to complete) <br />2T (411 <br />Important Notice <br />Disposal facility below must be <br />notified in ADVANCE before delivery <br />of waste with SPECIAL HANDLING <br />instructions. <br />--° I herby warrant that the above material was picked up at the generator site <br />listed above and delivered without incident to the destination listed below. <br />Signature Driver Date <br />7 Section 3 Destination Information (disposal facility to complete) <br />Front Range Landfill <br />1830 WCR 5 POS 320 Waste Codes Volume Received Ticket # <br />Erie, CO 80516 <br />Yards ; Tons'. , Other <br />Phone: 303 - 673 -9431 <br />Fax: 303.673 -9432 Charge To y Grid Elevation <br />� r <br />Landfill Authorized Agent Name (print / type) Signature of Landfill's Authorized Agent Date <br />The material delivered above was received at the landfill. <br />White: Landfill Yellow: Generator i j / Pink: Transporter, Gold: Consultant <br />